Ken Fyie University of Calgary and Alberta Bone and Joint Health Institute Waiting Time Management Strategies for Scheduled Health Care Services Ottawa, Ontario – March 28, 2012

Motivation and research question Methodology Results Discussion and next steps

Involuntary Waits A system-related wait, caused by inability to meet demand Voluntary Waits Patient-related factors directly impacting the systems ability to deliver care in a specified timeframe Source: Marshall et al. (2012) – under submission

Inconsistent and incomplete measurement of waiting times From referral made to musculoskeletal (MSK) assessment to surgical consultation Little analysis about the context of delays Few published analyses of referral processing inside clinics – a black box from the outside MotivationMethodologyResultsDiscussion

Can the hip and knee referral process from primary care providers to orthopaedic specialists in Alberta be positively impacted by the introduction of an electronic referral tool? We: Qualitatively evaluate current referral practices Quantitatively evaluate three system measures reflecting current quality of care MotivationMethodologyResultsDiscussion

Data collected in three stages: Initial clinic visits, with semi-structured interviews Retrospective patient chart sampling Time and motion study of clinical staff Patients are consulting for hip and knee osteoarthritis for first time Primarily referred to clinics by GPs Three volunteer hip and knee clinics in Alberta MotivationMethodologyResultsDiscussion

Setting Number of surgeons MSK screening option available Integration between surgeons and clinics Complexity of patients Degree of Electronic Usage Clinic 1 ~ referrals per year Urban Multi- surgeon (10-20) Yes Highly integrated Handle all complexities Very advanced Clinic 2 ~ referrals per year Rural Single- surgeon No Moderate integration Low complexities Moderately advanced Clinic 3 ~ referrals per year Midsized city Multi- surgeon (2-9) Yes Moderate integration Handle all complexities Moderately advanced Alberta total: ~15,000 referrals across 9 hip and knee clinics MotivationMethodologyResultsDiscussion

Accessibility: – 1) Waiting times (business days) – Time referral made to time referral deemed complete Time referral deemed complete to time of first surgical consult – 2) % of patients seeking next available surgical consult – 3) Estimate of involuntary and voluntary waiting times Referral Appropriateness: – 4) % of referrals initially arriving complete and correctly directed – 5) Clinical rules for accepting referrals – 6) MSK screening usage Efficiency: – 7) Time spent by clinic staff evaluating each referral MotivationMethodologyResultsDiscussion

11-15% of the referral made to surgical consultation waiting time is involuntary Scheduling rules vary across clinics MotivationMethodologyResultsDiscussion From: Referral made Referral deemed complete Referral made To: Referral deemed complete Surgical consultation Clinic 1 Mean Median 90 th % Clinic 2 Mean Median 90 th % Clinic 3 Mean Median 90 th %

Red line: 90 th percentile time Tan line: Mean waiting time Green line: Median waiting time Note: few patients with long waiting time drive results MotivationMethodologyResultsDiscussion

Red line: 90 th percentile time Tan line: Mean waiting time Green line: Median waiting time Note: few patients with long waiting time drive results MotivationMethodologyResultsDiscussion

This is much higher than in literature (only 40%-70% in previous studies) % of referrals with next available surgeon option chosen % of referrals with specific surgeon selected % less waiting time: when next available is chosen Clinic 171%21% 36% (20 days) Clinic 2 Only one surgeon Clinic 380%20% 14% (21 days) MotivationMethodologyResultsDiscussion

Why are referrals rejected? Incomplete: referral variables not filled out Rules vary depending on clinic Most rejected referrals are due to incompleteness Incorrectly directed: cannot be treated at specific clinic Longest delays associated with this % of initially rejected referrals Primary Reason Clinic 113% Missing x-rays Clinic 249% Missing BMI (height/weight) Clinic 3 No information MotivationMethodologyResultsDiscussion

MSK screening results in fewer currently non-surgical patients seeing a surgeon Clinic 1Clinic 3 % of patients referred to MSK asssessment 87% (105 of 121) 38% (19 of 50) % of MSK patients assessed surgical 67% (70 of 105) 32% (6 of 19) % of MSK patients assessed nonsurgical 33% (35 of 105) 68% (13 of 19) These assessments resulted in: - 29% of referred patients at clinic % of referred patients at clinic 3 not seeing a surgeon for a surgical consultation MotivationMethodologyResultsDiscussion

Clinic staff Most referrals take ~9-14 minutes Referrals with missing information take longer Most staff have other work areas in addition to referral processing Technology could increase efficiency (duplicate data entry, scanning information) MotivationMethodologyResultsDiscussion

Clinical time tracking is consistent Bone and Joint Clinical Network defined waiting times Clinical processing rules vary What is necessary on a referral form How patients are prioritized Whether triaging (MSK assessment) is available Requirements prior to consult or surgery Feedback to GPs MotivationMethodologyResultsDiscussion

Reduced waiting times: cut initial involuntary times by up to 20 days All Alberta patients can choose next available surgeon Consistent referral forms to minimize missing information: eliminate the 10-50% not initially accepted Urgency scoring: get care to worse-off patients quicker Reductions in certain tasks by clinic staff: save 8 minutes in scanning time MotivationMethodologyResultsDiscussion

Electronic referral should be evaluated to determine how system outcomes change Must account for multiple changes occurring at once Voluntary waiting times should be separated Basic standardization of the referral process should occur Differing clinic processing rules need to be considered Reduces variation, creates one consistent queue for patients MotivationMethodologyResultsDiscussion

Current referral practices show some inefficiencies and gaps in knowledge, producing worse system outcomes Electronic referral and central intake can potentially improve referral processing and system outcomes Future analysis needed when electronic referral is implemented MotivationMethodologyResultsDiscussion

Alberta Bone and Joint Health Institute: Tanya Christiansen Karen Phillips Stephen Weiss Christopher Smith Cy Frank Betty Smith University of Calgary: Deborah Marshall Tom Noseworthy Aish Sundaram Staff at three volunteer hip and knee clinics in Alberta Funding provided in part from hSITE/NSERC and Alberta Health Services, and the Alberta Osteoarthritis AIHS Team Grant